Quality of Life After a Low Anterior Resection in Elderly Patients

See Article on Page 27-32

In recent years, many patients with rectal cancer patients have been surgically treated using a low anterior resection. The low anterior resection has become the operation of choice for patients with mid or lower rectal cancer. A number of studies on the use of a low anterior resection to treat patients with rectal cancer have reported the results in terms of oncologic outcomes and quality of life (QoL). The majority of the patients with low rectal cancer are treated with sphincter-sparing surgery such as a low anterior resection, and 50% to 90% of those patients experience bowel dysfunction, known as low anterior resection syndrome [1]. Surgeons have to consider not only the surgical methods for treating low rectal cancer but also the QoL after surgery.

These days the incidence of low rectal cancer in the elderly is increasing. Especially in elderly patients, the QoL after a resection of the rectum, with or without colostomy, has become an important issue. The decision of which operation to perform would depend on a number of variables, including the likely oncologic outcome, the life expectancy of the individual patient and the patient’s attitude toward a permanent stoma. For anterior resection patients, the functional outcomes are substantially more variable, being affected by factors such as preoperative sphincter function and anastomotic complications [2]. After a low anterior resection, elderly patients may easily experience fecal incontinence due to age-related functional changes of the anal sphincter. Fecal incontinence is known to occur more often in females than in males [3]. Elderly females have been shown to have a reduced rectal compliance and sensation compared with younger females [4]. Engel et al. [5] suggested that elderly patients (patients older than 70 years) had significantly worse sexual function, but higher emotional function, than did patients younger than 70 years. Hendren et al. [6] reported that advanced age was not associated with a decrease in sexual function after surgery, but rather was as an independent indicator of sexual inactivity. Cornish et al. [7] suggested that a low anterior resection (LAR) was associated with significantly better physical function than an abdominoperineal resection (APR). They also said that sexual function was better following a LAR than an APR and that there was no significant difference in social function following a LAR versus an APR. Individualization of care for rectal cancer patients is essential, but a policy of avoidance of an APR cannot currently be justified on the grounds of QoL alone.

In surgery for cancers in the lower third of the rectum, a LAR without a permanent stoma is preferable in terms of long-term QoL for the patients [8]. However, the Cochrane Collaboration [9,10] showed no significant overall differences in QoL between the anterior resection and the APR groups. Manceau et al. [11] suggested that the overall QoL for elderly patients who underwent surgery for rectal cancer did not seem to differ from that for younger patients. However, physical, cognitive, and social functions are affected to a greater degree. In a study by Phillips et al. [12], 92 patients older than 75 years were assessed 1 year after an anterior resection. Of those patients, 78 (85%) considered themselves to have minor or no difficulties with continence. Whitehead et al. [13] reported that age alone should not be a contraindication to a restorative rectal resection. Older adults are known to have a deterioration of the pelvic diaphragm muscles and external anal sphincter, leading to a greater incidence of continence and defecation disorders. The prevalence of anal incontinence is about 8% in the general population, 2.5% for individuals between 20 and 30 years of age, more than 15% in those older than 70 years, and higher in institutionalized patients.

In this study, the authors reported the QoL in terms of fecal incontinence in elderly patients after rectal cancer surgery. They reported that elderly females had significantly worse scores on the fecal incontinence QoL subscales coping/behavior (P = 0.043) and depression/self-perception (P = 0.004) compared with younger females. Elderly females also scored worse on coping/behavior (P = 0.010) and depression/self-perception (P = 0.036) compared with elderly males. Younger and elderly males had comparable scores [14].

The QoL of patients who have had rectal cancer is closely associated with the severity of the low anterior resection [1]. After a low anterior resection, elderly patients who have had rectal cancer have a decreased QoL due to fecal incontinence. Elderly female patients are affected more easily than the elderly male patients in terms of fecal incontinence. I think that elderly female patients should especially be informed about the results and the risks of a low anterior resection, including fecal incontinence. A large observational study is needed to identify risk factors and to further improve the QoL for elderly patients after a LAR.